Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1939 | SC |
NPI | 1003360462 |
---|---|
Provider Name | Dr. Jordan Lee Ellis Alexander |
First Address | Columbia, SC 29229-7955 |
Second Address | Columbia, SC 29229-7955 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2016 |
Last Update Date | 15/08/2016 |